1 Please complete this Statement of Means carefully and accurately. If you need assistance in completing this Statement of Means, you may wish to contact your solicitor (if you have one), the Money Advice and Budgeting Service or a Citizen’s Advice Centre.

2 If you deliver a statement of means which is false to your knowledge in a material particular, you may be arrested and imprisoned for a period not exceeding three months.

3 If you are in receipt of any social welfare payments it is most important in your own interests that you bring with you your social services card and produce it to the Court.

4 If any of your details do not fit in the space provided, please attach a separate sheet giving those details.

5 You are advised to keep a copy of this Statement of Means and bring it with you to Court.

To the District Court Clerk

at..............................

As required by the summons served on me in the above-named proceedings, I now lodge the following statement of my means.

€
per week (gross)

€
per week (net)

1. Income:

Please set out in this section each means by which your income is earned (e.g. employment) or the source of your income (e.g. social welfare benefits) and the amount per week you receive from each means or source.

a.

€

b.

€

c.

€

2. Outgoings:

Please set out below in this section details of your outgoings (e.g. rent, household expenses, gas/electricity, loan repayments) and the amount per week you pay for each.

a.

€

b.

€

c.

€

3. Other court orders:

Please set out in this section if you are at present making payments on foot of any other court orders (e.g. other instalment orders, maintenance etc). If you are, please give details of the amounts and the reference numbers and bring with you to court copies of any relevant documents. If you are not, strike through this section.

a.

Reference no.:

€

b.

Reference no.:

€

c.

Reference no.:

€

4. Assets:

Please give in this section a description of any assets which you own (e.g. money in bank, car etc) and the approximate value of each. If you have no relevant assets, strike through this section.

a.

€

b.

€

c.

€

5. Other liabilities:

Please give in this section a description of any other liabilities you have which you are not currently repaying and the approximate value of each. If you have no relevant liabilities, strike through this section.

a.

€

b.

€

c.

€

6. Persons for whose support I am legally or morally liable:

Please give details in this section of other people who you are legally or morally liable to support, for example your children or any relative who relies on you. If there is no relevant person, strike through this section.

Name:

Address:

Age:

Name:

Address:

Age:

Name:

Address:

Age:

I say that, to the best of my knowledge and belief, the particulars given above and on any attached sheet are accurate and true. I understand that if I deliver a statement of means which is false to my knowledge in a material particular, I may be arrested and imprisoned for a period not exceeding three months.